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Dr. Alpana Mohta Ranka, MD, DNB, IFAAD, is a triple-board-certified dermatologist with over 100 research publications in peer-reviewed scientific journals.

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Malar Rash AKA Butterfly Rash AKA Lupus Rash vs. Rosacea

Updated: 3 days ago

Malar rash and rosacea are often confused due to their facial redness and similar appearance. This article clarifies the differences and suggests dermatologist-recommended management strategies for both conditions.


Malar Rash vs. Rosacea

What is Malar Rash?


Malar rash is a distinctive symptom of lupus erythematosus, presenting as a butterfly-shaped erythema over the cheeks and bridge of the nose. It's often a sign of an underlying autoimmune connective tissue disorder and can be aggravated by factors like sun exposure and stress.


What is Rosacea?


Rosacea is a chronic skin disorder characterized by facial redness, small red bumps, and visible blood vessels, primarily affecting the central face. Triggers include dietary factors, ultraviolet radiation exposure (by the sun, sun lamps, and tanning beds), and emotional stress.


Distinguishing Features of Malar Rash

  • Pattern:

  • Butterfly Shape: Symmetric butterfly-shaped rash on cheeks and nose, usually sparing the nasolabial fold.

  • Color and Texture:

  • Appearance: The rash is typically red or purplish and may be slightly raised or flat.

  • Severity:

  • Range: Can range from mild to severe, with some patients experiencing only light redness, while others have more pronounced rashes.

  • Associated Conditions:

  • Systemic Symptoms: Often linked with systemic symptoms of lupus or systemic sclerosis. More than half of the patients with systemic lupus erythematosus (acute cutaneous lupus) develop malar rash.

  • Trigger Factors:

  • Sun Exposure: Exacerbated by sun exposure due to photosensitivity.

  • Stress: Emotional or physical stress can trigger or worsen the rash.

  • Temperature Changes: Extreme cold or heat can also aggravate the rash.

  • Associated Sensations:

  • Pain: The rash can be painful to touch.

  • Burning or Itching: Some patients may experience a burning sensation or itching in the affected area.

  • Other Symptoms:

  • Systemic Involvement: Other potential symptoms of lupus include skin rash, ulcers on the mouth or nose, prolonged fever, inflammation of joints resulting in arthritis, inflammation in the lungs, heart, or kidneys, neurological complications, reduced hemoglobin level, and abnormal levels of blood cells.

  • Lupus Flares:

  • Definition: Lupus flares refer to periods when the symptoms of lupus become more pronounced or severe. These flares can vary in intensity and duration, often causing significant discomfort and requiring medical attention to manage.

  • Triggers: Flares can be triggered by various factors, including sun exposure, stress, infections, certain medications, and hormonal changes.

  • Management: Effective management of lupus involves identifying and avoiding triggers, adhering to prescribed treatments, and maintaining regular follow-ups with healthcare providers to monitor the disease's activity.

  • Treatment:

  • Medications: Focuses on managing lupus with medications like corticosteroids, other immunosuppressants such as azathioprine, mycophenolate mofetil, cyclophosphamide, belimumab.

  • Sun Protection: Strict sun protection measures, including consistent usage of broad-spectrum sunscreen with an SPF of 50 or higher.


Distinguishing Features of Rosacea


  • Location: Affects central face, including forehead and chin.

  • Symptoms: Persistent redness, flushing, small red bumps, pustules, dilated pores, phymatous swellings (of nose, chin, or forehead), and sometimes eye irritation.

  • Trigger Factors: Includes spicy food, alcohol, caffeine, sun exposure, temperature extremes, and emotional stress.

  • Treatment: Involves avoiding triggers, gentle skincare, and medications like azelaic acid, oxymetazoline, brimonidine, sulphur, and ivermectin, which offer anti-inflammatory benefits and help in reducing redness of skin. In severe cases, oral Isotretinoin, Propranolol, antibiotics like Doxycycline, Pulsed Dye Laser, surgical excision, or CO2 laser excision of phymatous lesions might be required.

  • Do check out our comprehensive guide on azelaic acid usage in the article on Azelaic Acid for Skin.


Diagnosis of Lupus and Rosacea

Diagnosis of Lupus

Lupus, specifically systemic lupus erythematosus (SLE), is a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues, causing widespread inflammation and tissue damage. The exact cause of lupus is unknown, but it is believed to involve a combination of genetic, environmental, and hormonal factors.


Diagnosing lupus, specifically systemic lupus erythematosus (SLE), involves a comprehensive approach combining clinical evaluation, laboratory tests, and sometimes imaging studies. Here's an outline of the diagnostic process:

  1. Clinical Evaluation:

  • Detailed Medical History: A thorough review of the patient's medical history, including symptoms, family history of autoimmune diseases, and potential environmental triggers.

  • Physical Examination: Focus on identifying characteristic signs such as the malar rash, joint tenderness or swelling, and other systemic symptoms indicative of lupus.

  1. Laboratory Tests:

  • Antinuclear Antibody (ANA) Test: A primary screening test for lupus, as most people with lupus have a positive ANA test.

  • Anti-DsDNA and Anti-Smith Antibodies: Specific markers for lupus, often used to confirm the diagnosis after a positive ANA test.

  • Complement Levels (C3, C4): Lower levels can indicate lupus activity.

  • Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): Elevated levels may suggest inflammation associated with lupus.

  • Complete Blood Count (CBC): Can reveal anemia, leukopenia, or thrombocytopenia.

  • Urinalysis: To check for kidney involvement, a common complication in lupus.

  1. Additional Tests:

  • Skin Biopsy: If the rash is atypical, a biopsy can help distinguish between lupus and other conditions.

  • Renal Biopsy: May be necessary if there are signs of kidney involvement to assess the extent of renal damage.


Diagnosis of Rosacea

The diagnosis of rosacea primarily relies on clinical evaluation, as there are no specific tests for the condition. Here’s how it is typically diagnosed:

  1. Clinical Evaluation:

  • Detailed Medical History: Includes discussion of symptoms, triggers, and any family history of rosacea or related skin conditions.

  • Physical Examination: Focus on identifying characteristic signs such as facial redness, visible blood vessels, and the presence of papules and pustules. The distribution of these signs, typically on the central face, is also noted.

  1. Assessment of Symptoms:

  • Flushing: Persistent or transient facial redness.

  • Papules and Pustules: Often mistaken for acne but without comedones (blackheads or whiteheads).

  • Telangiectasia: Visible blood vessels on the surface of the skin.

  • Phymatous Changes: Skin thickening and enlargement, particularly on the nose (rhinophyma).

  • Ocular Symptoms: Including dryness, irritation, and eyelid swelling.

  1. Differential Diagnosis:

  • Rule Out Other Conditions: The clinician will distinguish rosacea from other skin conditions such as acne, seborrheic dermatitis, and lupus, often by examining the distribution and type of lesions and considering the patient's overall health and symptoms.

  1. No Specific Tests:

  • Rosacea is Diagnosed Clinically: Unlike lupus, there are no blood tests or biomarkers for rosacea. The diagnosis is based on the presence of typical clinical features and the exclusion of other conditions.


Lifestyle Management


Both conditions benefit from high sun protection with atleast SPF 50, usage of physical sunscreens containing zinc oxide or titanium dioxide, and a gentle skincare routine. Hypoallergenic fragrance-free moisturizers are recommended for rosacea, as discussed in the article on Sensitive Skin and Rosacea.


Conclusion


Properly differentiating between malar rash and rosacea is essential for effective treatment. Consult a dermatologist for personalized advice.

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